课件：妊娠内科合并症.ppt

Medical Complications of Pregnancy 妊娠期合并症,Objectives目 的,Describe selected medical emergencies exclusive to pregnancy描述仅在妊娠出现的医疗急症 Describe selected medical conditions that can cause serious complications in pregnancy描述可能危及生命的妊娠合并症 Formulate a plan for diagnosis and treatment of these conditions制定诊断及治疗的计划,Conditions Exclusive to Pregnancy仅在妊娠出现的症状,Severe pre-eclampsia严重子痫前期 Eclampsia子痫 HELLP syndromeHELLP综合征 Acute fatty liver of pregnancy (AFLP)妊娠期急性脂肪肝,Conditions That Complicate Pregnancy使妊娠复杂化的症状,Deep venous thrombosis (DVT)深静脉血栓 Pulmonary embolism (PE)肺栓塞 Disseminated intravascular coagulation (DIC)弥漫性血管内凝血 Human immunodeficiency virus (HIV) infection HIV感染,Hypertensive Disorders of Pregnancy 妊娠相关高血压症,Pregnancy Induced Hypertension妊高症,PIH无蛋白尿 (no proteinuria),HELLP Syndrome HELLP综合征,Chronic Hypertension (Elevated BP prior to 20 weeks)慢性高血压（妊娠前20周血压升高）,6-8% of all gestations妊娠的6-8%,Preeclampsia 子痫前期(proteinuria +/- edema)蛋白尿水肿,Eclampsia 子痫,Severe Preeclampsia 严重子痫前期,Pre-Eclampsia子痫前期,Classic Triad:经典三联征 Hypertension (140/90)高血压 Proteinuria (1+ or 300 mg/24h)蛋白尿 Generalized edema (least reliable)广泛性水肿 Hypertension and proteinuria must be present on two occasions 6 hr apart高血压和蛋白尿需在至少间隔6小时、二次以上 Rapid weight gain is supportive evidence 体重迅速增加支持诊断,Diagnostic Criteria for Severe Preeclampsia 严重先兆子痫的诊断标准,Headaches 头痛,Visual Disturbances 视力紊乱,Pulmonary Edema 肺水肿,Hepatic Dysfunction 肝功异常,RUQ or Epigastric Pain 右上腹或上腹痛,Oliguria少尿 Elevated Creatinine肌酐上升 Proteinuria of 5 g or more in 24 hrs 24小时尿蛋白5g以上,Thrombocytopenia or hemolysis 血栓性血小板减少或溶血,Systolic BP收缩压 160 to 180 mm Hg Diastolic BP舒张压 110 mm Hg,Risk Factors for Preeclampsia 先兆子痫的危险因素,Nulliparity Maternal age 40 Twin gestation Family history of pre-eclampsia or eclampsia Chronic hypertension Chronic renal disease Antiphospholipid syndrome Diabetes mellitus Angiotensin gene T235,初产妇 母年龄超过40岁 双胎 以前妊娠有先兆子痫 慢性高血压 慢性肾病 抗磷脂综合征 糖尿病 血管紧张素T235基因,Prevention: No Proven Benefit 预防：尚未证明获益,Correct nutritional deficiencies改善营养缺乏 Magnesium镁 Zinc锌 Omega 3 fatty acids 欧米茄3脂肪酸 Change prostacyclin / thromboxane balance: 改变前列环素/血栓烷的平衡 Aspirin阿斯匹林,Clinical Course of Preeclampsia 子痫前期临床病程,Eyes Arteriolar Spasm Retinal Hemorrhage Papilledema Transient Scotomata,Respiratory System Pulmonary Edema ARDS,Liver Subcapsular Hemorrhage Hepatic Rupture,Hematopoietic System HELLP Syndrome DIC,CNS Seizures Intracranial Hemorrhage CVA Encephalopathy,Pancreas Ischemic Pancreatitis,Kidneys Acute Renal Failure,Uteroplacental Circulation IUGR Abruption Fetal Compromise Fetal Demise,Clinical Course of Preeclampsia子痫前期临床病程,中枢神经系统 子痫发作 颅内出血 脑血管意外 脑水肿,Pancreas胰腺 Ischemic Pancreatitis 缺血性胰腺炎,Kidneys肾脏 Acute Renal Failure 急性肾功能衰竭,子宫胎盘循环 胎儿生长受限 早剥 胎儿受损 胎儿死亡,眼睛 小动脉痉挛 视网膜出血 视乳头水肿 一过性的盲点,呼吸系统 肺水肿 ARDS,肝脏 包膜下出血 肝脏破裂,造血系统 HELLP综合征 DIC,Management of Severe Preeclampsia 严重先兆子痫的处理,Admit to hospital, monitor closely at bedrest 住院卧床休息，密切监测 Treatment goals:治疗的目标 Prevent seizures预防抽搐 Lower BP to prevent cerebral hemorrhage降压预防脑出血 Expedite delivery, balancing maternal condition and fetal maturity 提前分娩，权衡母情况与胎儿成熟的状况,Maternal Evaluation对母亲的评估,Vitals, neuro checks, and DTRs q15-60 min. until stable生命体征、神经系统的检查，深腱反射每15-60分钟一次，直至稳定 Foley catheter - output and dipstick protein hourly foley尿管每小时计量排量和蛋白量 External monitoring NST 外检测NST Labs: Blood count, BUN, creatinine, AST, ALT, LDH, electrolytes and uric acid 实验室：血常规、BNU、肌酐、肝酶、电解质、尿酸 Meds: MgSO4 IV; BP meds for diastolic 110 药物：静脉硫酸镁，若舒张压110用降压药,Magnesium Sulfate硫酸镁,Preferred anticonvulsant 抗抽搐首选 Slows neuromuscular conduction and decreases CNS irritability减慢神经肌肉的传导、降低中枢神经系统的激惹性 No significant effects on blood pressure对血压无显著影响 4-6 gram IV load, followed by infusion of 1-3 grams / hour静脉4-6克，然后每小时1-3克,Magnesium Levels硫酸镁浓度,Normal Therapeutic Loss of patellar reflex Somnolence Respiratory depression Paralysis Cardiac arrest,mg/dl 1.3 to 2.6 4 to 8 8 to 10 10 to 12 12 to 17 15 to 17 30 to 35,Antidote is calcium gluconate one gram IV over 3 minutes 拮抗剂是葡萄糖酸钙1g缓慢（3分钟以上）静脉注射,Antihypertensive Medication 抗高血压药物,Goal: Maternal diastolic 90-110 mm Hg 目标：母亲舒张压90-110 Choices of parenteral agent静脉用药选择 Beta blockers (labetalol)贝塔阻滞剂 Vasodilators (hydralazine)扩血管药物 Oral alternatives (slower onset) 口服替代药（起效慢） Calcium channel blockers (nifedipine) 钙离子拮抗剂（尼非地平） Methyldopa (Aldomet)甲基多巴,33-34 weeks大于34周,Delivery引产,Delivery Decisions - Severe Preeclampsia 严重子痫前期分娩判断,Maternal deterioration?母亲情况恶化？ Severe IUGR?严重胎儿生长受限 Fetal compromise?胎儿窘迫 In labor?已在分娩过程？ 34 weeks gestation?孕期34周,28-32周,Corticosteroids糖皮质激素 Antihypertensive drugs抗高血压药 Daily evaluation of maternal and fetal conditions until 33-34 Weeks每天评估母婴情况直至33到34周,Yes,Delivery within 24 hours 24H内引产,Amniocentesis羊穿,Immature fluid不成熟羊水,Corticosteroids糖皮质激素 Deliver 48 hours later 48H后引产,Mature fluid成熟羊水,No,Adapted from University of Tennessee, Memphis, management plan for patients with severe preeclampsia, Sibai, BM, in Obstetrics: Normal and Problem Pregnancies, 3rd Edition, Gabbe, SG, Niebyl, JR, Simpson, JL.,Delivery Decisions for Severe Preeclampsia II严重先兆子痫的分娩决策,Vaginal delivery preferred倾向于阴道分娩 Cesarean delivery for剖宫产用于 Continuous seizures or other emergency连续抽搐或其它急症 Fetal distress胎儿窘迫 Unfavorable cervix宫颈不成熟 Severe prematurity很早的早产 Anesthesia麻醉 Epidural vs. general硬膜外或全麻,Postpartum Management产后处理,Improvement usually rapid after delivery 产后常很快地改善 Risk of seizure greatest in first 24 hours 在产后24小时内抽搐的危险最大 Magnesium continued for 24 hrs 连续使用硫酸镁24H Continue monitoring serum MgSO4 levels, BP, urine output监测硫酸镁、血压及尿量 Watch for signs of fluid overload 注意水负荷过重的体征,Eclampsia 子痫,Appearance of seizures in a patient with preeclampsia先兆子痫的患者发生抽搐 Etiology uncertain病因不清 cerebral edema, ischemia possible causes脑水肿、缺血可能是原因 BP often significantly elevated, but in 20% can be normal (diastolic 90)血压常升高，但20%的患者并不高（舒张压90mmHg) Can occur before, during or after delivery可发生于分娩前、分娩时、或产后,Seizure Management抽搐的处理,Avoid anticonvulsant polypharmacy 避免抽搐时使用多种药物 Protect airway to minimize aspiration 保护气道以减少吸入 Prevent maternal injury 预防母亲的损伤 Give MgSO4 to control the convulsions 予以硫酸镁控制抽搐 When stable, plan for delivery 当病情稳定，计划分娩,HELLP Syndrome HELLP综合征,Atypical presentation of severe preeclampsia重度先兆子痫的不典型表现 Acronym HELLP: 首字缩写代表代表 Hemolysis溶血 Elevated Liver enzymes肝酶升高 Low Platelets血小板降低,Clinical Presentation of HELLP HELLP的临床表现,Extremely variable极大的变异性 Common findings:常有的发现是 RUQ pain, epigastric pain, nausea, and vomiting右上腹痛、上腹痛、恶心、呕吐 85% hypertensive85%有高血压 Time of diagnosis诊断时间 2/3 antepartum, 1/3 postpartum 2/3在产前，1/3产后 Mid-second trimester to several days postpartum孕中期的中间至产后数日,Differential Diagnosis of HELLP HELLP的鉴别诊断,Biliary colic, cholecystitis胆绞痛、胆囊炎 Hepatitis肝炎 Gastroesophageal reflux胃食道返流 Gastroenteritis胃肠炎 Pancreatitis胰腺炎 Ureteral calculi or pyelonephritis输尿管结石或肾盂肾炎 ITP or TTP特发性血小板减少性紫癫或血栓性血小板减少性紫癫,Laboratory Findings in HELLP HELLP 的化验所见,Hemolysis溶血 Abnormal peripheral smear异常的周缘血涂片 Total bilirubin 总胆红素 1.2 mg/dl LDH 600 IU/L Liver enzymes肝酶 AST (SGOT) 70 IU/L Platelet count血小板计数 100,000 per mm3 Used to classify severity用以判断严重性,2019/4/20,25,可编辑,Management of HELLP HELLP的处理,Similar to severe preeclampsia:同于子痫前期 Stabilize mother Evaluate fetus for compromise Determine optimal timing/route of delivery Use CEFM and manage BP and fluid status 稳定母亲 评估胎儿是否受损 确定合适的分娩时间及方式 使用连续胎心电子监护及处理血压及液体的状况 All women should receive MgSO4 while symptomatic or in labor 所有的孕妇在有症状或临产时都使用硫酸镁,HELLP: New Treatments新治疗,Dexamethasone 10 mg IV q12h when platelets 100,000血小板100000时候静脉地塞米松10mg每12h Platelets for active bleeding, or if 20,000 活动性出血或者板20000输注血小板 Plasmapheresis: limited success, but not routinely recommended 血浆置换：有限的成功率但并不被常规推荐,Acute Fatty Liver of Pregnancy 妊娠期急性脂肪肝(AFLP),Occurs in one of 7,000-16,000 pregnancies发生率1/700016,000妊娠 Presents in third trimester:于妊娠晚期发生： Vomiting呕吐(76%), abdominal pain腹痛(43%) Anorexia厌食(21%), jaundice黄疸(16%) May progress to liver failure, including ascities and renal failure 可进展为肝衰、腹水、肾衰和脑病 Differential includes HELLP, acute hepatitis, or toxin-induced liver damage 鉴别诊断 HELLP、肝炎、毒素引起的肝损伤,Diagnosis of AFLP 诊断,SGOT (AST) elevated, but 500 IU/LAST升高，但常500IU/L Bilirubin elevated, but 5 mg/dl胆红素升高， 但常5mg/dl PT and PTT prolonged, fibrinogen decreased凝血酶及凝血酶原时间延长，纤维蛋白原减少 Liver biopsy diagnostic肝活检可诊断，但很少需做 correct coagulation defects first首现纠正凝血障碍 Delivery is most important part of treatment分娩是最重要的治疗部分,Venous Thromboembolism 静脉血栓栓塞,Includes DVT and PE包括深静脉栓塞形成及肺栓塞 Occurs in 1/1000-2000 pregnancies 发生率为1/1000-2000妊娠中 Leading cause of maternal mortality in developed countries在发达国家为孕产妇死亡的首要原因 5-15% recurrence risk in future pregnancies 以后妊娠的复发率为5-15% Chronic venous insufficiency is common sequelae 栓塞后综合征是常见的后遗症,Risk Factors for VTE 静脉血栓栓塞的危险因素,Virchows Triad三联征 Hypercoagulability高血凝 Venous stasis静脉淤滞 Vascular damage血管损害 Age 35年龄35岁 Weight 80 kg体重超过80kg Multiparity多产 Family history of VTE家族史,Deficiencies:缺陷 Antithrombin抗凝血酶 Protein C蛋白C Protein S蛋白S Gene variants:基因变异 Factor V Leiden Prothrombin凝血素 Lupus anticoagulant狼疮抗凝血剂,Clinical Presentation of DVT DVT 的临床表现,75% antepartum - 51% by 15 weeks 产前75%，51%15周 Swelling and discomfort of the leg腿疼痛及肿胀 Calf circumference difference 2 cm小腿周径差值2cm Signs of superficial phlebitis浅表静脉炎的体征 Positive Homans sign may be present Homan征非特异性,Consider anti-coagulation therapy考虑抗凝,Impedance plethysmography阻抗容积描记术,Ultrasound超声,Meets diagnostic criteria for DVT符合诊断标准,Equivocal不确定,Begin anti-coagulation therapy开始抗 凝治疗,Repeat ultrasound vs. IPG vs. abdominal shielded venography重复检查或腹部遮盖的静脉造影,Meets diagnostic criteria for DVT符合诊断标准,Begin anti-coagulation therapy开始抗 凝治疗,Equivocal不确定,DVT Diagnosis,Pulmonary Embolism (PE)肺栓塞,Majority occur postpartum2/3发生于产后 Mild dyspnea and tachycardia progressing to cardiopulmonary collapse表现各异；从轻度的呼吸困难及心动过速到心肺虚脱 Treat (O2, hemodynamic support) and evaluate simultaneously治疗（吸氧、血液动力学的支持、复苏（ABCS）及评估同时进行 ABG will show decreased PO2 (85 mm Hg) and increased A-a gradient 血气显示氧分压下降A-a阶梯增大,PE Evaluation评估,CXR胸片 30% normal 30%正常 May show atelectasis or elevated diaphragm可能肺膨胀不全或膈面抬高 EKG 心电图 Sinus tachycardia 窦性心律 Classic “S1 Q3 T3” pattern经典“S1 Q3 T3” 型 V/Q scanVQ扫描 Treat if high probability 如果可能性大则治疗 PE unlikely if low probability如果可能性则可能不是PE Evaluate for DVT if V/Q equivocal若VQ不明确则评价DVT,Initial evaluation supports diagnosis of PE (ABC, CXR, ECG)实施检查ABC, CXR, ECG,Symptoms/risk factors suggesting PE症状或高危因素提示可能PE,Anti-coagulation therapy抗凝疗法,Intermediate中度可能,Normal正常,V/Q,Low probability低可能,High probability高可能,Begin heparin 肝素,Pulmonary angiogram肺血管造影,Emboli present 有血栓,Emboli absent 无血栓,No therapy不治疗,Diagnostic Tests for Pulmonary Embolism诊断性检查,VTE Treatment治疗,Anticoagulation抗凝 Data lacking - adapted from non-pregnant patients缺乏数据-主要从非孕妇资料中获得 Heparin肝素 Safest agent - does not cross placenta最安全-不通过胎盘 Role of LMW heparins under study低分子肝素地位仍在研究 Warfarin华发令 Does cross the placenta通过胎盘 Can cause fetal damage in 1st trimester妊娠早期死产的危险,VTE Prophylaxis静脉血栓栓塞的预防,Low risk patients: begin in early pregnancy低危患者妊娠早期即开始 Aspirin 75 mg qd -OR-每日阿斯匹林75mg或者 Unfractionated heparin units SQ q12h整分子肝素每12H5000 High risk: begin in early pregnancy or 4-6 weeks before previous VTE高危患者：妊娠早期即开始或先前VTE前4-6周 Unfractionated heparin 7500-10,000 units SQ q12h整分子肝素每12H7500-10,000 LMWH daily低分子肝素每天40 mg (adjust dose for weight根据体重调整剂量),Treatment of Acute VTE急性VTE治疗,Rapidly institute anticoagulation with UFH 迅速使用整分子肝素建立抗凝 5000 unit IV bolus 5000单位负荷量 1300 units per hour continuous infusion 每小时1300持续静脉泵入 Maintain aPTT at 1.5-2.5 times normal 使得aPTT保持在正常的1.5到2.5倍 Continue for 5-10 days连续5-10天 Follow with UFH 10,000 units SQ q12h 再用整分子肝素每12小时10000单位 If postpartum若为产后 Begin warfarin the first day第一天就用华法令 Stop UFH when INR is between 2.0-3.0 INR 达到2.0-3.0时候停用整分子肝素,Delivery with Anticoagulation抗凝时候分娩,Risk of significant hemorrhage is low 大出血危险不大 Consider reduced UFH dose vs. stopping at onset of labor 考虑整分子肝素减量 或 临产时停药 Spinal or epidural analgesia safe with prophylactic doses of UFH 预防用量的整分子肝素硬膜外麻醉是安全的 Avoid regional anesthesia if IV heparin or high-dose SQ regimens如果静脉肝素或者高剂量SQ药物则应避免局麻,DIC弥漫性血管内凝血,Simultaneous activation of clotting system and clot lysis凝血系统与纤溶系统同时被激活 Depletes clotting factors, causing bleeding凝血因子被耗竭，导致出血 Clots can lead to ischemia血栓导致缺血 Hemolysis can lead to significant anemia溶血导致贫血 Underlying cause can be difficult to detect潜伏的病因不易探查,Diagnosis of DIC诊断,Oozing from venipuncture and IV sites, easy bruising, petechiae静脉穿刺点渗血，容易淤血，皮下出血点 Lab evaluation:实验室检查 aPTT and PT-INR fibrin split products and D-dimer纤维蛋白降解产物与D二聚体 fibrinogen纤维蛋白原 platelet count and H/H血小板计数与H/H,Treatment of DIC治疗,Correction of underlying cause is key!治疗潜在的病因是关键 Often related to pregnancy complication常常与妊娠并发症有关 Delivery necessary需要分娩 If cause uncertain, replace coagulation factors:如果病因不清，则置换凝血因子 Maintain platelets 100,000保持血小板100000 Maintain fibrinogen (from FFP or cryoprecipitate) 保持纤维蛋白原 150 mg/dl Avoid heparin if patient actively bleeding如果病人有活动性出血则避免使用肝素,HIV in Pregnancy妊娠HIV感染,Goal: decrease vertical transmission 目标：降低垂直感染 Can be decreased from 25% to 2% with antepartum treatment如果妥善处理可以由25%危险性降低为2% Risk factors for transmission传播的危险因素 Hi